ボリビア多民族国
地域保健システム向上プロジェクト
終了時評価調査報告書
平成24年3月
（2012年）
独立行政法人国際協力機構
ボリビア事務所
序 文
ボリビア多民族国の妊産婦死亡率は290/10万出生（2005年、WHO統計情報）、乳幼児死亡率 は63/1000出生（2003年ボリビア人口･保健アンケート調査）で、南米でも最も劣悪な水準です。妊産 婦死亡の主な原因は産科合併症ですが、この多くは検診を含む、適切な周産期ケアが実施できれば防 ぐことができるものです。また、乳幼児の死亡原因の大半は急性呼吸器感染症、下痢症であり、これらの 疾病は母親が早い段階で乳幼児を受診させ、適切な処置を施せば、大半は命を取り留めることができ ます。しかしボリビアでは、保健医療施設が近隣にないという物理的な問題以外にも、住民の保健医療 施設への不信又は文化的な要因等から、施設の受診に対する抵抗感が根強く存在しています。保健 医療施設においても、医療従事者の能力不足から適切なケアが提供できない場合も少なくありません。 これらの複合的な要因により、基礎的な母子保健医療サ－ビスの提供が適切に機能していない状況で す。 当機構は、2001年11月から2006年10月までの5年間実施した「サンタクルス県地域保健ネットワ－ク 強化プロジェクト」で、1)保健医療サービスの質の向上（産科・小児科）、2)住民参加保健活動、3)レ ファラル・カウンターレファラルシステムの定着、4) 保健行政・財政管理システムの構築支援、5)医療機材 維持管理体制の構築支援の5つの重点分野の活動（FORSA モデル）を行いました。その結果、住民 の保健医療サ－ビスへのアクセスがパイロット地区で向上し、地域住民の健康改善に寄与していることが 確認されたため、地域保健システム向上のモデルとしてサンタクルス県だけでなく、中央政府にも広く認識 されるに至りました。同プロジェクトの成果をボリビア国内へ広く普及し、地域の保健システムの質を改善 させることを目的として、2008年4月より2012年6月までの4年間の予定で｢地域保健システム向上プロジェクト｣を実施しています。 今般、2012年6月のプロジェクト終了を控え、プロジェクト活動の実績や実施プロセスを確認し、評価5 項目（妥当性、有効性、効率性、インパクト、自立発展性）の観点から評価を行うべく、終了時評価 調査団を派遣しました。本報告書は、その調査結果を取り纏めたものです。 ここに、本調査の実施にあたりご協力をいただいた関係者の方々に、深い謝意を表するとともに、プロジ ェクトの発展に向けて、より一層のご支援を賜りますようお願い申し上げます。 平成24年3月
独立行政法人国際協力機構
ボリビア事務所長松山 博文
目次
序文 目次 地図 写真 略語表 評価調査結果要約表（和文・英文） 第 1 章 終了時評価調査の概要 ... 1 1-1 調査団の派遣の経緯と目的 ... 1 1-2 調査団の構成と調査日程 ... 2 第 2 章 終了時評価調査の方法 ... 6 2-1 PDM ... 6 2-2 評価グリッド ... 6 2-3 調査方法 ... 7 2-4 評価 5 項目 ... 7 2-5 主な調査項目 ... 8 2-6 データ収集方法と情報源 ... 10 2-7 調査・評価上の制約 ... 12 第 3 章 プロジェクトの概要 ... 133-1 JICA による技術協力の期間 ... 13 3-2 ターゲットグループ ... 13 3-3 対象地域 ... 13 3-4 関係機関 ... 13 3-5 支援機関 ... 17 3-6 プロジェクトの要約 ... 17 3-7 実施体制 ... 18 第 4 章 実施プロセスと実績 ... 20 4-1 実施プロセス ... 20 4-2 投入実績 ... 27 4-2-1 日本側投入 ... 27 4-2-2 ボリビア側投入 ... 32 4-3 活動実績 ... 34 4-4 成果の達成状況 ... 39 4-4-1 成果 1 （保健医療サービスの質向上） ... 39 4-4-2 成果 2 （住民参加型保健活動）... 41 4-4-3 成果 3 （レファラル・カウンターレファラルシステムの定着） ... 43 4-4-4 成果 4 （保健行政・財務管理システムの改善） ... 47 4-4-5 成果 5 （医療機材維持管理体制の構築支援） ... 49 4-4-6 成果 6 （政策・制度レベルへの貢献） ... 52
4-5 プロジェクト目標達成の見通し ... 54 4-5-1 プロジェクト目標の指標 1 ... 54 4-5-2 プロジェクト目標の指標 2 ... 56 4-5-3 プロジェクト目標の指標 3 ... 57 4-5-4 プロジェクト目標の指標 4 ... 58 4-4-5 プロジェクト目標の指標 5 ... 60 4-6 上位目標達成の見通し ... 61 第 5 章 評価結果 ... 64 5-1 評価 5 項目による評価結果 ... 64 5-1-1 妥当性 ... 64 5-1-2 有効性 ... 65 5-1-3 効率性 ... 67 5-1-4 インパクト ... 69 5-1-5 持続性 ... 71 5-2 効果発現に寄与した要因 ... 73 5-3 問題点及び問題を惹起した要因 ... 74 5-4 結論 ... 74 第 6 章 提言と教訓 ... 77 6-1 提言 ... 77 6-2 教訓 ... 78
第 7 章 プロジェクト延長終了までに対処すべき事項 ... 81 7-1 PDM の改訂 ... 81 7-2 PDM1 指標のフォローアップ ... 81 付属資料 1. ミニッツと合同評価報告書（西文） 2. PDM0（評価用 PDM）（和文） 3. PDM1（評価用 PDM）（和文） 4. 評価グリッド（和訳） 5. 主要面談者リスト（和文）
表目次 表 1 DAC5 項目による評価の視点 ... 8 表 2 データ収集方法と情報源 ... 11 表 3 カウンターパートの交代 ... 23 表 4 日本人専門家投入実績 ... 27 表 5 ボリビア人のプロジェクトチームスタッフ投入実績 ... 28 表 6 カウンターパート研修実績 ... 29 表 7 日本側ローカルコスト負担実績... 31 表 8 機材供与実績 ... 31 表 9 カウンターパート投入実績 ... 33 表 10 ローカルスタッフ投入実績 ... 33 表 11 ボリビア側プロジェクト運営コスト負担実績 ... 33 表 12 各成果別研修受講者数実績 ... 36 表 13 各成果別活動進捗 ... 37 表 14 成果 1 指標の達成状況 ... 40 表 15 成果 2 指標の達成状況 ... 43 表 16 成果 3 指標の達成状況 ... 46 表 17 成果 4 の指標の達成状況 ... 48 表 18 成果 5 指標の達成状況 ... 51 表 19 研修を修了した維持管理技術者の配置状況 ... 52
表 20 成果 6 の指標達成状況 ... 53 表 21 対象 3 県での施設分娩率 ... 56 表 22 サンタクルス県のターゲットグループ住民の行動変容 ... 57 表 23 ターゲット地域の保健医療施設の問題解決能力の改善を示す事実（サンタクルス県） ... 58 表 24 ターゲット地域の保健医療施設の事務・財務管理の効果と効率性改善を示す事実（サ ンタクルス県） ... 59 表 25 上位目標達成に向かうインパクト ... 61 表 26 上位目標の指標の現状 ... 62 表 27 延長フェーズ終了前にフォローアップすべき PDM 指標 ... 84 図目次 図 1 プロジェクト実施体制の組織図 ... 18
プロジェクト位置図
（地図の区分は郡）
パンド県 5 市
ベニ県 6 市
写真
新生児の小児疾患統合管理研修 医師のエコー研修 レファラルシステムの強化 母親に対する教育セッション コミュニティ活動 バイオセキュリティ研修略語表
略語 正式名称（西/英） 和訳
AIEPI Atención Integral a las Enfermedades
Prevalentes de la Infancia 統合的小児疾患管理 AIEPI Nut Atención Integral a las Enfermedades
Prevalentes de la Infancia, con enfoque Nutricional
栄養に焦点をおいた小児疾患統合 管理
CAI Comité de Análisis de Información
情報分析委員会 CIDA Canadian International Cooperation
Agency カナダ国際協力庁
CCC Comité de Coordinación Conjunto
合同調整委員会 CEP Comité de Ejecución del Proyecto
実施委員会 COP Comité de Operación del Proyecto
技術委員会 ENDSA Encuesta Nacional de Demografía y Salud
国家人口保健調査 FORSA Fortalecimiento de la Red de Salud
保健ネットワーク強化 IME Instituto Municipal de Equipos Médicos
（サンタクルス市）医療機器メンテ ナンスセンター
JICA Japan International Cooperation Agency
独立行政法人国際協力機構 M/M Man Month
人/月 MSD Ministerio de Salud y Deportes
（ボリビア）保健スポーツ省 OPS Organización Panamericana de Salud
米州保健機構 PDM Matriz de Diseño de Proyecto
POA Plan Operativo Anual
年間活動計画 PSIEC Proyecto de Salud Integral de Extensión
Comunitaria 地域保健システム向上プロジェクト SAFCI Salud Familiar Comunitaria Intercultural 多文化コミュニティ家族保健 （政
策） SALMI Sistema de Administración de Logística
Medicamento de Insumo 投入薬剤調達管理システム SEDES Servicio Departamental de Salud
県保健局 SIAF Sistema de Información Administrativa
Financiera 財務情報システム SISME Sistema Integrado de Servicios Médicos de
Emergencia 救急医療サービスシステム SNIS Sistema Nacional de Información en Salud 国家保健情報システム
SOAPS Software de Atención Primaria en Salud プライマリーヘルスケアソフトウェア SUMI Seguro Universal Materno Infantil
ユニバーサル母子保険 SUSACRUZ Seguro Universal de Salud de Santa Cruz
サンタクルス県ユニバーサル健康保険 UNICEF United Nations Children's Fund
国連児童基金
VIPFE Viceministerio de Inversión Pública y Financiamiento Externo
開発企画省公共投資対外金融次 官室
評価調査結果要約表 1. 案件の概要 国名：ボリビア多民族国 案件名：地域保健医療システム向上プロジェクト 分野：保健医療 援助形態：技術協力プロジェクト 所轄部署：JICA ボリビア事務所 協力金額（2012 年 6 月時点見込）：1.52 億円 協力期間 延 長 前 ： 2008.04.01 ～ 2012.06.30 延 長 後 ： 2008.04.01 ～ 2012.11.30 先方関係機関： 保健スポーツ省、サンタクルス県保健局、ベニ県保健局、パ ンド県保健局、サンタクルス市役所人間開発局・医療機材 メンテナンスセンター（IME）および救急サービス総合システ ム（SISME）、サンタクルス県内の 12 保健医療ネットワーク 事務局、ベニ県内の 2 保健医療ネットワーク事務局、パンド 県内の 1 保健医療ネットワーク事務局、サンタクルス市日本 病院、トリニダ母子病院、コビハ市ロベルト・ガリンド病院、 プロジェクト対象のサンタクルス県 30 市1、ベニ県 6 市2、パン ド県 5 市3 日本側協力機関：国立国際医療研究センター 他の関連協力：「サンタクルス総合病院建設計画（1983 1 サンタクルス・デ・ラ・シエラ、コトカ、ポロンゴ、ラ・グアルディア、エル・トルノ、ワルネス、オキナワ、ブエナ・ビスタ、サン・カルロス、ヤパカニ、サ ンフアン・デ・ヤパカニ、ポルタチュエロ、サンタ・ロサ・デル・サラ、コルパ・ラ・ベルヒカ、バジェ・グランデ、トリガル、モロ・モロ、ポストレル・バジェ、 プカラ、サマイパタ、パンパ・グランデ、マイラナ、キルシージャス、モンテロ、サーベドラ、ミネロス、フェルナンデス・アロンソ、サン・ペドロ、コマラパ、 サイピナ 2 サン・ホアキン、サン・ラモン、プエルト・シレス、マグダレナ、バウレス、ウアカラヘ 3 コビハ、ポルベニール、ボルペブラ、ベジャフロール、フィラデルフィア
年）」、「サンタクルス総合病院プロジェクト（1987～1992 年）」、「サンタクルス医療供給システム（1994～1999 年 ）」 、 「サ ン タク ル ス公衆 衛生 向上（ 1996 ～ 1999 年）」、「サンタクルス県地域保健ネットワーク強化プロジェク ト（2001～2006年）」、「ラパス市母子保健に焦点を当て た地域保健ネットワーク強化プロジェクト（2004～2005 年）」 1-1 協力の背景と概要 ボリビア多民族国（以下、「ボ」国という）は、「国家開発５ヵ年行動計画（1997-2002 年）」の中で、 保健医療分野の取り組むべき重点課題のひとつとして第一次保健医療施設への住民のアクセスが改善する ことを挙げていた。その重点課題を踏まえ、2001 年 11 月から 2006 年 10 月までの 5 年間実施された技術 協力プロジェクト｢サンタクルス県地域保健ネットワ－ク強化プロジェクト（以下、「FORSA SCZ Ph.1」とい う）｣は、1)保健医療サービスの質の向上（産科・小児科）、2)住民参加保健活動、3)レファラル・カウンター レファラルシステムの定着、4) 保健行政・財政管理システムの構築支援、5)医療機材維持管理体制の構築 支援の 5 つの重点分野の活動（以下、「FORSA モデル」という）を行った。その結果、住民の保健医療サ－ ビスへのアクセスがパイロット地区で向上し、地域住民の健康改善に寄与していることが確認されたところ、地 域保健医療システムの向上モデルとしてサンタクルス県のみならず、「ボ」国政府にも広く認識されるに至った。 そのため、FORSA SCZ Ph.1 の成果を「ボ」国国内へ広く普及し、地域の保健医療システムの質を改善させる ことを目的として、本プロジェクトの実施に至った。
1-2 協力内容 (1) 上位目標 ミレニアムゴールにもとづいて「ボ」国住民の保健向上に貢献する。 (2) プロジェクト目標 本プロジェクト対象地域の住民が質の高い予防、プロモーション、診療を有すための保健医療サービスネッ トワークが強化される。 (3) 成果 1) 保健医療施設及び保健医療ネットワーク事務局の従事者が、習得した知識を活用し、保健医療 サービスの質に責任を有する。 2) 情報を有し、組織化された住民が、保健の権利を行使し、保健医療ネットワークとの調整に積極 的に参加する。 3) 県及び保健医療ネットワークレベルで適切にレファラル・カウンターレファラルシステムが機能する。 4) 保健医療施設に保健行政・財務管理システムが導入され機能している。 5) 医学的技術の信用度が国家保健医療システムのパラメータ内にある。 6) FORSA モデルが保健スポーツ省または県、市の保健責任者により機関決定される。 (4) 投入（2012 年 2 月、終了時評価時点） 日本側：ボリビア人コンサルタント派遣 7 名(延べ 134 カ月)、機材供与 0.3 億円、日本人専門家派遣 8 名(延べ 159 日)、研修員受入 11 名、ローカルコスト負担 0.49 億円 相手側：主要カウンターパート 37 名、ローカルコスト*負担 0.22 億円 *サンタクルス日本病院によるプロジェクト事務所、光熱費、運転手・秘書人件費の負担額
２．評価 (1) 妥当性 以下により本プロジェクトは、「ボ」国のニーズに合致しており、妥当性は高かった。 ① 国家開発計画との合致 「ボリビア国家開発計画 2006-2011 年」の上位目標である「人として尊厳のある生活の回復」の柱と して、貧困削減のための社会開発支援を目指している。ここでは、教育、保健、安全な水などの基本 的社会サービスへのアクセスを改善し、最も脆弱な社会階層が直接受益することを目指している。本プ ロジェクトは、この中の保健医療分野で主に貧困層向けサービスのアクセス改善に貢献するために 2008 年に開始された。本プロジェクト開始以来、「ボ」国政府の国家開発政策は継続しており、本プロジェク トとの合致に変化はない。 ② 保健セクター開発計画との整合性 保健スポーツ省の「保健セクター開発計画 2010-2020 年」では、上記国家開発計画の上位目標を具 現化するため、a)保健医療サービスへのユニバーサルアクセスに主眼を置いた多文化コミュニティ家族保 健政策（以下、「SAFCI 政策」という）、b) 健康増進と社会参加、c) 健康の主権と教義4、の 3 つ の軸を設定している。本プロジェクトの FORSA モデルは、上記 3 つの軸に含まれ、その達成を支援する 手段と位置づけることができる。このように、本プロジェクトは「保健セクター開発計画」と上位目標を共 有し、その達成手段の一部になっている点で、両者の整合性は極めて高い。 ③ SAFCI政策との整合性 本プロジェクトは、2008 年に保健スポーツ省から発表された国家政策である SAFCI 政策の実現を支援 4 住民が自らの健康のために主体的に活動をするうえで参考になる行動指針。
する役割を担っていると位置づけられる。SAFCI 政策では、「マネジメントモデル」と「保健ケアモデル」が 示されている。本プロジェクトの成果 2 の FORSA モデルは、SAFCI 政策のマネジメントモデルが目指す 地域保健活動の強化を実現するための知見を提供している。住民参加保健活動を除く FORSA モデ ルは、SAFCI 政策の保健ケアモデルが目指す保健行政サービスの改善を実現する役割を担う。このよう に、本プロジェクトは SAFCI 政策を実現するための手段であるため、両者の整合性と補完性は極めて 高い。 ④ 日本の「ボ」国に対する援助政策との合致。 対ボリビア国別援助方針（2009年10月）を具現化するためにJICAは、国別事業実施計画2011 年の中で、「母と子どもの健康に焦点をあてた地域保健医療ネットワーク強化プログラム （PROFORSA）」定めており、母子保健分野は重要課題の一つに挙げられている。これらにより本プ ロジェクトは、「ボ」国および我が国の開発政策に合致している。 (2) 有効性 本プロジェクトにより、FORSA モデル5を用いた能力開発が行われた結果、地域の保健医療サービスネットワ ークの能力が包括的に強化される見込みであるところ、有効性は概ね高いと判断される。特にサンタクルス県 では以下の５つの成果が、大きな貢献要因となった。しかしベニ県では 2011 年 8 月に活動を開始、パンド県 では 2011 年 10 月に活動を開始したが、11 月からの雨季のため活動は停滞し現在、成果が発現するまでに は活動が進捗していない。そのためベニ県とパンド県は、プロジェクト終了時点で有効性の検証を行うべきであ る。 8 つの農村部の保健医療ネットワークでは、本プロジェクト開始後に施設分娩率が 8％増加した（プ 5 FORSA1で開発された5つの重点分野の活動の中でそれぞれ使われている手法の総称。
ロジェクト目標の指標 1）。 地域住民が適切な予防保健の知識を獲得して実践する傾向にある。その中で、保健医療サービス を以前より積極的に活用するようになる見込みである（プロジェクト目標の指標 2）。 1 次、2 次保健医療施設でのケアの質は改善し、問題解決能力は向上する傾向にある（プロジェク ト目標の指標 3）。 保健医療施設での事務・財務管理の効果と効率性が改善し、保健医療活動をより適切に支援で きる傾向にある（プロジェクト目標の指標 4）。 医療機材の予防メンテナンスと管理について、恒常的に支援する人材が配置される見込みである （プロジェクト目標の指標 5）。 (3) 効率性 サンタクルス県では、「廃棄物とバイオセキュリティ、院内感染に関する研修の実施」、「医療機材の維持管 理とオペレーションの研修を受けた市による、技術者の配置、ワークショップの整備、予算の確保」など一部の 課題がある。成果の達成状況は概ね良好といえるが、FORSA モデルの活動を一貫して調整するための技術 の移転や、JICA の PCM 手法を使ったプロジェクト全体の精緻なモニタリングをするためには、4 年間で合計 2M/M、年 1 回で各回 2 週間の日本人総括専門家の投入量は十分ではなかったことは教訓とすべきであ る。「ボ」国側カウンターパートの人事異動という外部条件により活動が一時停滞したことも、効率性に負の影 響を及ぼした。しかし、我が国による過去の技術協力プロジェクト「サンタクルス県地域保健ネットワーク強化プ ロジェクト（2001～2006 年）」、「ラパス市母子保健に焦点を当てた地域保健ネットワーク強化プロジェクト （2004～2005 年）」で作成されたマニュアル、ガイドライン、そして教材などを積極的に活用したことは、有効 性を高める要素であった。
(4) インパクト 本プロジェクトで実施された住民参加保健活動により、コミュニティで保健活動のリーダーが育成され、また 住民の連帯意識の強化が醸成された結果、デング熱の発症認知件数がゼロ、5 歳以下の幼児の下痢の認 知件数が激減するなど、地域の健康改善に大きな影響を及ぼした。本プロジェクトにより医療従事者の診療 技術の向上が図られたことで、地域住民の信頼を得て外来患者が増加したこと、乳幼児死亡率と妊産婦死 亡率が改善したことは、インパクトが大きいと判断できる。さらには女性が住民参加保健活動に参加すること で、彼女らの社会参加の機会と範囲が広がり、家庭以外の多様な知識に触れ、学ぶ機会が増えた。 その 結果、女性が家庭内やコミュニティ内で自分の意見・意志を表明することができるようになったことは、ジェンダー の観点で正の影響を与えた。 (5) 持続性 以下により本プロジェクトは、本プロジェクト実施による効果が期待できるため、持続性は高いと判断され た。 本プロジェクトの活動費用の中で JICA が負担してきた研修費用、また日本病院が負担してきたプロジェクト 事務所とその維持費、事務スタッフと運転手の人件費などの費用の負担は今後、受講者となる各市が確保 することを合同調整委員会で公約したところ、財政面での持続性が確保されたと判断できる。また、現場レベ ルの技術者や医療関係者を含む人材は、人事異動の範囲が限定的であるため、技術的な持続性は良好 である。妥当性の項で述べたように、本プロジェクトの FORSA モデルは、保健スポーツ省が推進する SAFCI 政 策の枠組みと合致し、その実現のための手段として一体化しているため、政策面での持続性は極めて高いと 判断される。更にFORSA モデルは、技術的にも普遍性の高いテーマを扱っているため、政権や政策を越えて有 効である。
３．特記事項 (1) 本プロジェクトの期間の延長 サンタクルス県の対象地域では、計画された活動がプロジェクト終了時点までに概ね完了すると見込まれ、 各成果はほぼ達成見込みである。同県ではプロジェクト目標も概ね達成される見通しが強い。しかし、ベニ県 とパンド県では、雨季による研修活動の停滞により、計画された活動がプロジェクト期間の 2012 年 6 月までに 完了する見込みは極めて低い。そのためこの 2 県での、各成果の達成を確認し、その適用可能性を検証する ためには、計画された活動が完了する見込みの 2012 年 10 月まで延長が必要と判断する。 (2) 住民参加保健活動の有用性 FORSA モデルを使った住民参加保健活動の実施で、受益者である住民の第１次保健医療機関に対す る意識の変化と行動変容が確認された。すなわち、地域の連帯意識が強化されて住民参加保健活動が実 施されるなど、保健医療活動へのアクセスが顕著に改善し、5 歳未満児の栄養失調や下痢の認知件数の減 少に貢献した。つまり、住民参加保健活動の結果、地域の保健活動での住民のニーズが明確となり、活動 実施の段階で住民が自主的に活動の一翼を担う体制ができあがり、活動の効率性と持続性の確保に目立 つ成果が見られた。この成果により、地域保健活動の計画から実施、フィードバックの全段階における住民の 参画の有用性が明らかになった。 (3) 自立性の高い運営管理システムの構築（人事異動に影響されない体制） 本プロジェクトの実施中、「ボ」国側のマネジメントレベル職員の人事異動が行われたが、FORSA モデルの 技術委員会を中核とする、現場レベルで活動を担う組織・人材にはその影響が少ないことを確認した。そのた め FORSA モデルの活動を計画する際、自立性の高い実施体制を現場レベルで構築することにより、活動目 標の達成度や有効性が高まることが期待できる。
(4) 普遍性の高い FORSA モデルの活用 FORSA モデルは、医療関係者の技術向上、また住民の健康を醸成させることに主眼を置いた能力開発モ デルとして構築された。その後、SAFCI 政策が保健スポーツ省より打ち出されたが、その枠組みを実現するため の手段として、同モデルは適用可能である。つまり「技術的に普遍性の高い能力開発モデル」は、保健全般に わたる政策に適用できる可能性が高く、政策実現に普遍的に貢献することが期待できる。 (5) 事業進捗監理の体制（活動計画の設定・見直し） 本プロジェクトは、ボリビア人主体の運営管理体制により、我が国の保健医療分野での協力経験や成果 を、JICA の PCM 手法にもとづきさらに拡大することを目的として、活動が開始された。この場合、達成目標、 成果指標、活動内容を精緻に設定・修正するためには、現地人材のみに依存するのではなく、JICA の PCM 手法を熟知している日本側による適切な支援が行われることが望ましい。 (6) 研修監理システムの構築 FORSA モデルは、保健医療システム強化、さらには住民の健康改善に有効であることがすでに実証されて いた 5 つの FORSA モデルにより構成されており、その有効性が本プロジェクトで実証された。しかし、同モデルの 研修では、各 FORSA モデル内の研修は適切に運営されているものの、研修内容の再現性を高めるための仕 組みや、研修を総合的に企画し運営管理する仕組みがモデルに含まれていないという課題が明らかになった。 その課題を解決し、他県への普及・拡大をより容易にするためには、研修のための教本の見直し、研修のさら なる有用性・継続性を確保するためにカリキュラムとマネジメントマニュアルの作成が求められる。 ４．添付書類 ・終了時評価調査報告書
Summary of Results of Evaluation
1. Overview of Project
Country name: Plurinational State of Bolivia Project Name: The Project to Improve the Regional Healthcare System
Sector: Health and medical care Form of Aid: Technical cooperation project Department with Jurisdiction: JICA Bolivia
Office
Aid Amount (estimate as of June 2012): 152,184,000 yen
Cooperation Period
April 1, 2008 – June 30, 2012 Related Organizations in Bolivia:
Ministry of Health and Sports; Santa Cruz Department’s Health Service Bureau; Beni Department’s Health Service Bureau; Pando Department’s Health Service Bureau; Santa Cruz City Hall’s Medical Equipment Maintenance Center (ME) and the Integrated Emergency Medical Service System (SISME); 12 health network offices in Santa Cruz Department; 2 health network offices in Beni Department; 1 health network office in Pando Department; Hospital Universitario Japones (Japanese University Hospital) in Santa Cruz;
Maternal-Infant Hospital in Trinidad; Hospital Roberto Galindo in Cobija; and 30 cities in Santa Cruz
Department, six cities in Beni Department and five cities in Pando Department covered by the Project
Cooperation Period: Four years
Cooperating Organizations on the Japanese Side: None
1-1 Background and Overview of Cooperation
The first phase of the five-year project, Project for Strengthening Regional Health Network in Santa Cruz Department (FORSA1), carried out from November 2001 to October 2006, focused on five areas (hereinafter “sub-system”): (1) improving the quality of healthcare services; (2) encouraging healthcare activities through community participation; (3) establishing a referral and counter-referral system; (4) supporting the
development of a healthcare administration management system; and (5) supporting the development of a medical equipment maintenance system. As a result, residents’ access to healthcare services improved in the pilot regions, and the project confirmed that better access contributes to improvements in the health of local residents. This encouraged not only the Santa Cruz Department but also the national government to recognize the project as a model for improving the regional healthcare system. To achieve this end, this project, i.e., the Project to Improve the Regional Healthcare System (hereinafter the “Project"), is currently underway for a four-year period from April 2008 to June 2012 to spread the results of the FORSA1 project throughout Bolivia and improve the quality of the regional healthcare system. The counterparts (C/Ps) were designated as the Ministry of Health and Sports, Santa Cruz Department’s Health Service Bureau, Beni Department’s Health Service Bureau, and Pando Department’s Health Service Bureau, among others.
This terminal evaluation was intended to evaluate and confirm the Project activities’ achievements and results ahead of the Project’s completion in June 2012, provide advice on what should be accomplished in the remaining period, and discuss countermeasures that should be taken after the cooperation period has ended.
1-2 Description of Cooperation
(1) Overall Goal
To contribute to improvements in the health of Bolivia’s residents based on the Millennium Development Goals.
(2) Project Purpose
To strengthen the healthcare service network that provides residents in the target area with high-quality preventative care, healthcare promotion, and medical examinations and treatment.
(3) Output
1) Employees of healthcare facilities and healthcare network offices apply the knowledge they have acquired and take responsibility for the provision of high-quality services.
2) Organized residents with information exercise their rights to healthcare and actively participate in rectifying healthcare networks.
3) The referral and counter-referral systems at the department and healthcare network levels function appropriately.
4) Administrative management and financial management systems are introduced to and function in healthcare facilities.
5) Trust in medical technology is within the parameters of the national healthcare system.
6) Those responsible for healthcare in the departments and cities make decisions about the sub-system. (4) Input (at time of evaluation)
Japanese side:
Dispatch of Bolivian consultants: 7 (over 134 months) Donation of equipment and materials: 2,631,222 Bs Dispatch of Japanese experts: 8 (over 159 months)
Acceptance of trainees: 11 Local costs borne: 4,319,868 Bs
Bolivian side:
Major counterparts: 37
Local costs* borne: 194,670 Bs
* Costs for Project office, electricity and heating costs, and personnel costs for driver and secretary borne by Hospital Universitario Japones in Santa Cruz
2. Overview of Evaluation Study Team
Study team members
Team leader Hirofumi Matsuyama Head of JICABolivia Office
Cooperation planning Keiichi Ohsato Member of First Group (Healthcare and Medical Sector), JICA Bolivia Office
Evaluation analysis Hiromi Osada Senior Consultant, IC Net Limited Interpretation Atsuko Yoshikawa Japan International Cooperation Center
Study period January 29– February 18, 2012 Type of Evaluation: Terminal evaluation
3. Overview of Evaluation Results 3-1. Confirmation of Results
(1) Extent of Achievement of Project Purpose
The Project covers the three departamento (departments) of Santa Cruz, Beni and Pando. Of these, the departments of Beni and Pando have not yet achieved the Project Purpose because activities started late, in August-October 2011, soon after which the rainy season started, which made it difficult to move forward with activities. The extent to which indicators were achieved in the Santa Cruz Department is shown below, demonstrating that Santa Cruz achieved the Project Purpose.
Indicator 1, “facility delivery rates in regions covered by Project,” increased 8% after the Project started in the healthcare networks in eight rural areas. However, the facility delivery rates are declining in the four healthcare networks in urban regions. This can be attributed to an increase in private facilities in urban regions, where more women are likely delivering their children. The study team confirmed that there were changes in residents’ behavior, referred to in Indicator 2, “rate at which the Project target group residents know about high-quality healthcare services and exercise their rights to it.” For example, as a result of the Project, residents have greater awareness and take action so that they are more effective in receiving services at medical facilities, and participate proactively in local activities to promote healthcare. The achievement of Indicator 3, “rate at which patients are treated and their conditions resolved at primary healthcare facilities,” showed an improved capacity to resolve problems. For example, the Project’s training to improve the quality of medical care, healthcare activities with community participation, the adoption of a referral and
counter-referral system, and the development of an appropriate maintenance and management system for equipment and materials enabled primary medical facilities to utilize new medical technology and provide appropriate medical treatment. Indicator 4, “rate of healthcare facilities with effective and efficient administrative and financial management,” confirmed improvements in administrative and financial management at respective healthcare facilities. Software such as SIAF1and SALMI2were appropriate
introduced and utilized so that patient information could be appropriately managed and the medicine provided to patients did not go out of stock or fall into surplus. As for Indicator 5, “the percentage of cities in close contact with technicians trained in preventative maintenance and management of medical equipment,” seven cities, or 70% of the 10 cities that had received training as of the evaluation, had assigned part-time or full-time technicians.
(2) Extent to which Outputs have been achieved
1) Extent of achievement in Santa Cruz Department
Although Output 1 has only been achieved in part, achievement of the Outputs is generally good.
1 Sistema Informatica de Administración Finaciera: Financial information system
[Output 1] The quality of care has improved at primary and secondary healthcare facilities and their capacity to resolve problems is improving.
[Output 2] Healthcare activities through community activities have been well established in primary facilities, and a system to continually sustain and expand activities is being set up.
[Output 3] The referral and counter-referral system is beginning to take hold and to provide feedback that will help improve the problem-solving capacity at primary facilities.
[Output 4] Software supporting effective and efficient medical activities is beginning to function and information and materials needed for medical activities are beginning to be provided.
[Output 5] Techniques for expert maintenance and operation of medical equipment are spreading to facilities in the target region and are helping to improve the quality of medical care. In tandem with this, a methodology for the spread of technology has been developed.
[Output 6] Six manuals and guidelines developed or revised in the Project were authorized by the Servicio Departamental de Salud (Departmental health service, or SEDES) and are recognized as tools that will help achieve national policy. Moreover, Project activities are being implemented together with the activities of departments’ and cities’ healthcare networks.
2) Extent of achievement in Beni Department and Pando Department
Activities have only just started in these departments and there has not been any output that could be ascertained as of yet.
3) Issues remaining for each Output
The following issues, which would not be achieved by June 2012 when the Project is due to be completed, remain to be resolved.
Santa Cruz Department
Some of the activities to achieve Output 1
- Training on waste, bio-security, and infection within the hospital Beni Department
Activities to achieve Outputs 1 and 2 Pando Department
Activities to achieve Outputs 1, 2 and 5
4) Issues that must be addressed on an ongoing basis after the Project is completed
The follow issues should be addressed on an ongoing basis even after the Project is completed in order to enhance the achievement of the respective Outputs.
Issues related to Output 3
- Follow-up to further enhance the quality of referrals; encouraging implementation of counter-referrals Issues related to Output 5
- Assignment of technicians, upgrades to workshops, securing budgets by cities that have received training in the maintenance, management and operation of medical equipment
3-2 Summary of Evaluation Results (1) Relevance
Relevance was extremely high in the following respects:
1) Consistency with Bolivia’s National Development Plan 2006-2011
The government endeavors to support social development to reduce poverty, part of its “Bolivia Digna” (dignity for Bolivia) pillar to restore life with human dignity. This is intended to achieve “life with dignity” (Vivir Bien), the highest goal of the national development plan started in 2011. This involves improves access to basic social services such as education, health and safety and directly benefiting the most vulnerable part of society. This Project began in 2008 to contribute to the improvement of access to services in the health sector, primarily for poor people. Since the Project began, the Bolivian government’s national development policies have continued and there has been no change in their high consistency with this Project.
2) Consistency with development plans in the health sector
In order to achieve “life with dignity” (Vivir Bien), the highest goal of the national development plan, the Ministry of Health and Sports’ sector development plan3(Plan Sectorial de Desarrollo 2010-2020)
designates three focal points: a) universal access to Intercultural Family and Community Health (Salud Familiar y Comunitaria, or SAFCI); b) health promotion and social mobilization; and c) Sovereignty and Doctrines in health. The five sub-systems of this Project all include at least one of these three focal points and can thus be seen as means of supporting the achievement of the goal. As such, this Project shares Bolivia’s current health sector development plan and highest goal in common, and provides a means of achieving this goal in part. Accordingly, the consistency between the two is very high. 3) Consistency with SAFCI
This Project plays a role in supporting the achievement of SAFCI, the national policy announced by the Ministry of Health and Sport in 2008. There are two models for SAFCI: the management model and the healthcare model (Modelo de Atencion). The sub-system in Output 2 of this Project provides the expertise to strengthen regional healthcare activities, which is the goal of SAFCI’s management model framework. The sub-system for Outputs 1, 3, 4 and 5 plays a role in helping to improve healthcare administration services, which is the goal of SAFCI’s healthcare model. As such, this Project can be seen as a tool to realize SAFCI. Thus they are extremely consistent and complementary. 4) Consistency with Japan’s aid policy for Bolivia
One of the two pillars of Japan’s support for Bolivia in the Japanese Ministry of Foreign Affairs’ Bolivia Country Assistance Plan (April 2009), “support for social development to reduce poverty,” includes support for “the achievement of the Millennium Development Goals (MDGs), including poverty reduction in Bolivia.”
JICA is currently implementing the Programa de Fortalecimiento de Redes de Salud (PROFORSA), a project to strengthening the regional healthcare network with a focus on maternal and child health that is part of the JICA Country-Specific Project Implementation Plan for Bolivia 2011 to realize the Aid Guidelines for Bolivia (October 2009). This Project is one of the nine projects that make up
PROFORSA.
(2) Effectiveness
1) Santa Cruz Department
Outputs 1-6 in PDM are currently being achieved due to the capacity development made possible by the FORSA model in five areas, and the capacity of the regional healthcare service network is being strengthened at the levels shown below. In other words, the Project Purpose is being achieved at the following levels thanks to the achievement of the six outputs, and thus its effectiveness is high. 1. The facility delivery rate increased by 8% after the Project started in healthcare networks in eight
rural areas (Indicator 1 for the Project Purpose).
2. Local residents are acquiring appropriate knowledge about preventative healthcare and are putting it into practice. For example, they are more actively using healthcare services than before
(Indicator 2 for the Project Purpose).
3. The quality of care at primary and secondary healthcare facilities is improving and the capacity to solve problems is improving (Indicator 3 for the Project Purpose).
4. The effectiveness and efficiency of administrative and financial management at healthcare facilities are improving so that healthcare activities can be supported more appropriately (Indicator 4 for the Project Purpose).
5. Human resources to constantly support preventative maintenance and management of medical equipment are being appointed (Indicator 5 for the Project Purpose).
2) Departments of Beni and Pando
Activities for Outputs 1 and 2 began in Beni Department in August 2011, and activities for Outputs 1, 2 and 5 began in Pando Department in October 2011, but activities were slow to get underway since the rainy season started in November. Accordingly, activities have not progressed enough as of yet for any Outputs to have materialized and the Project Purpose has not been achieved to a level that could be measured. In other words, the Project has not reached a level at which the effectiveness of the FORSA model can be verified based on the achievement of Outputs and the Project Purpose.
(3) Efficiency
In Santa Cruz Department, although Outputs1 and 5 have only been achieved in part, achievement of the Outputs is generally good. Nevertheless, the input of Japanese experts, who are responsible for Project management, was not adequate, which should be taken as a lesson. In addition, the temporary suspension of
activities due to the external factor of Bolivian counterpart transfers had a negative impact on efficiency. The study results on the quality, quantity, and timing of input are outlined below.
1) Japanese and third-country experts
According to the committee members, the Japanese and third-country experts had the expertise and qualifications needed to support the achievement of the respective Outputs.
The total input of the Japanese expert, who served as Team Leader, in the amount of 2MM was insufficient to manage PCM methods (refer to discussion below in 3-4 (1)).
2) Bolivian counterparts
In Santa Cruz Department, the Project’s Technology Committee members are all experts in various fields, and many of these members have been involved on an ongoing basis since the FORSA1 project so they were very familiar with the technical content of FORSA’s five sub-systems. As a result, the committee members were able to begin training the target groups immediately after the Project began, and the members utilized the experience and expertise they had built up to efficiently carry out Project activities. In this way, the quality of the Bolivian personnel contributed significantly to the Project’s efficiency.
SEDES personnel transfers in the departments of Santa Cruz and Beni were the main cause of delays in the Project activities (refer to discussion below in 3-4 (2)).
3) Donated materials and equipment
The donated materials and equipment covered a wide range, including medical equipment such as medical ultrasound equipment, temperature-controlled baths, and Doppler equipment, as well as projectors used in activities aimed at improving health and computers installed with software for administrative and financial management. The materials and equipment all met local needs, are managed well and utilized adequately on site.
4) Training in Japan and third-country training
Four people participated in third-country training, undergoing training on healthcare activities through community participation at Federal University of Pernambuco in 2009. A total of seven people
participated in training in Japan, including two in group training on medical equipment maintenance and management in 2008 and five in group training on community health promotion in 2010. All of the training participants were Project activity supervisors or managers in the respective fields at the time. Of the 11 training participants, one retired after the training and one took a new job at a private clinic, leaving nine still working in similar positions.With the exception of the one person who retired, all of the training participants replied that they use the knowledge acquired in Japan in their current work, while a
counterpart dispatched to training used the training materials on health enhancement activities using Brazil’s Bambu method in her daily work in a healthcare post in Porfía in the city of Mineros. This indicates that the third-country and training in Japan were appropriate in terms of the selection of subjects, participants and training content.
5) Status of assignment of health network directors and health facility staff
Several health network directors in Santa Cruz Department were replaced during the Project implementation period. However, the health facility personnel were not replaced, and there were no major impediments to the Project activities.
(4) Impact
The information for the indicators for the Overall Goal came from the Encuesta Nacional de Demografia y Salud (ENDSA; Statistical Survey on National Demographics and Health), but the indicators could not be measured by the second half of 2012, when the next ENDSA is to be carried out. Nevertheless, it is fair to say that the Project’s impact has been substantial overall, given the impact it has had in moving closer to
achieving the Overall Goal, as well as the various positive impacts that the five sub-systems have had, as described below.
1) Impact on achieving Overall Goal
The terminal evaluation confirmed the impact described below and demonstrated that the Overall Goal is highly likely to be achieved. These examples show that health activities through community participation generate an impact because they draw in the effects of other medical sectors.
As a result of the Project, leaders of community health activities were fostered and residents’ spirit of cooperation was strengthened, which led to effective cleanup activities for the prevention of dengue fever. This led to a dramatic drop in the number of reported dengue fever cases in Centro de salud Mairana in the Florida health network from 30 in 2009 to zero in 2011.
Similarly, in the Centro de salud Mairana, an expanded hand-washing campaign led to a sharp drop in the number of reported cases of diarrhea in children under the age of five to about 60% of 2006 levels in 2011.
At the Red Obispo Santistevan health network’s Virgen de Fátima health center, partograms began to be used correctly so that they could be utilized appropriate in deliveries. As a result, residents’ trust increased and the number of pregnant women having medical exams at the center increased; this also contributed to an improvement in the mortality rate of women at the time of childbirth.
2) Spillover effect outside of target group
At the Centro de salud Mairana and the Centro de salud Reverendo Padre Miguel Gouldh in the Red Warnes health network, the targets of the health enhancement activities was expanded to the elderly in the community (adultos mayores).
The members of the health enhancement committees in Municpio Mairana and Municipio Montero participated in the Congreso Nacional de Promocin de Salud (National Conference on Health Promotion) held in Cochabamba in 2010 and gave presentations on their experiences.
The Project Technology Committee members served as training instructors on the FORSA method to members of the two JICA-FORSA project members in Cochabamba and La Paz. In addition, this led
to the sharing of experiences and information between the three projects. 3) Impact on gender issues
Women’s participation in community-based health activities widened the scope of their participation in society, and they were exposed to a range of knowledge outside of the home and had more
opportunities to learn, such as the actual conditions in the regional society in which they live as well as maternal-child measures and tactics to prevent disease (Municpio Mairana).
As a result of the above, women became skilled at thinking about and presenting their own views within the home and community (Municpio Mairana).
4) Contributions to SAFCI measures
Since this Project provides SAFCI with the knowhow and tools to realize its policy framework, we can expect the continuing spread of the FORSA model to other regions to contribute to the achievement of SAFCI’s policy goals.
(5) Sustainability
As described below, the organizational, institutional and technical sustainability at the site level is high. However, there are still organizational issues, such as setting a new system framework with IME, as well as the financial issue of securing a budget for activities after the Project is complete.
1) Policy aspects
As noted in the section on relevance, the five sub-systems of this Project’s FORSA model is consistent with the framework for SAFCI policies promoted by the current administration. It has been integrated as a tool to realize the policies, so sustainability on the policy side is extremely high. Moreover, the FORSA model addresses technically universal themes so its effectiveness goes beyond a particular administration or policy.
2) Organizational and institutional aspects Organization at local level
Project activities for Outputs 1-4 are incorporated in the everyday activities of the actors, centered on the technical committees for each of the sub-systems. Moreover, this structure is further enhanced through these Project activities. In these respects, the sustainability of the local organizations that carry out the activities for the four Outputs is high.
Personnel changes are limited for the actors who carry out activities locally, such as the local
healthcare service workers and equipment technicians. Thus the sustainability of staff at the local level is high.
Agreement with IME
The training implementation system for the operation and maintenance of medical equipment that IME in Santa Cruz carries out for other cities is maintained under a contract with the Project, but this contract loses its validity after the Project is complete. Accordingly, a new system that can sustain the
current activities after the Project will have to be set up. Project’s overall coordinating function
SEDES is responsible for coordinating the Project’s five outputs for the activities overall, but SEDES has not been able to perform this coordinating function adequately since it is unable to avoid the disruptions caused by the job hand-overs that occur with every political personnel transfer. For these reasons, the JICA Project Team provided support as necessary with the coordinating. Accordingly, the sustainability of the coordinating function that should be borne by SEDES is somewhat low.
3) Technical aspects
The technology and expertise to implement each of the Project’s sub-systems were established in FORSA1, and were further improved and updated through feedback as the Project was implemented. They were also incorporated in daily work within the health network. In these respects, the technical sustainability is high.
However, new technical inputs must continue in order to further enhance the current technical level. 4) Financial aspects
Up until this point, the training costs that have accounted for a large proportion of the Project’s activity costs have been borne primarily by JICA. In addition, the Project office and its maintenance costs, the human resource expenses for the office staff and driver have been covered by the Hospital
Universitario Japones in accordance with the Project agreement. The members of the implementation committee (Comite Ejecutivo del Proyecto) promised to secure the funding for these costs in October 2010 after the Project is over; efforts will need to be made to ensure that the committee specifies the exact funding source.
3-3 Factors Contributing to Production of Effect (1) Plan content
Under the Project’s implementation structure, the Project team made up of a total of five people—two Bolivian consultants employed by JICA, one administrative staff member and two staff members from the Hospital Universitario Japones—is responsible for coordinating Project activities and handling administrative work, while Japanese and third-party experts are provided for short periods. In terms of the logistics needed to implement training, this structure enabled efficient operations utilizing the strengths of Bolivians.
(2) Implementation process
As noted in the section on efficiency, in Santa Cruz Department many of the Project’s technical committee members have been involved since the FORSA1 project, which was a major contributing factor in efficiently implementing the Project activities.
Santa Cruz’s Hospital Universitario Japones assigned staff to work exclusively on the Project, provided a Project office and bore its management costs. In addition, many medical staff below the
level of hospital director led the five technical committees and gave considerable time and technology to improving training content and carrying out activities. The Hospital Universitario Japones’ strong commitment and leadership filtered down to other committee members and was a major contributing factor to the achievement of the Project’s Outputs.
3-4 Problems and Factors Provoking Problems (1) Plan content
The input of the Japanese expert, who served as Team Leader, for a total of 2M/M over four years, or two weeks per year, was insufficient for technology transfer to coordinate activities for the five sub-systems in an integrated manner and closely monitor the Project using JICA’s PCM method.
(2) Implementation process
In Santa Cruz Department, the SEDES head was replaced in the fourth quarter of 2011. As a result, the JCC’s authorization process in regards to the three points proposed in the interim progress study in June 2011—1) begin to expand activities in the departments of Beni and Pando, 2) revise the PDM, and 3) revise the Project implementation period—was time-consuming. This affected the start time of activities in the departments of Beni and Pando.
In Beni Department, the governor was replaced in December 2011 after the Project activities had started. As a result, department staff at SEDES and other offices have been replaced twice thus far. This delayed coordination work to start Project activities and the conclusion of agreements, and led in turn to delays in the Project activity schedule for this department.
3-5 Conclusion
This Project was initiated with the aim of expanding upon the work done in the Project for Strengthening Regional Health Network in Santa Cruz Department, carried out in 2001-2006, to strengthen health systems to five departments, including 30 cities in the Santa Cruz Department. It was also intended to spread the five sub-systems that had been shown in the former project to be effective in improving residents’ health: 1) improving the quality of healthcare services, (2) encouraging healthcare activities through community participation, (3) establishing a referral and counter-referral system, (4) supporting the development of a healthcare administration management system, and (5) supporting the development of a medical equipment maintenance system. In addition, the Project was to examine the possibility of introducing this system in other regions. Subsequently, the regions covered in this Project were changed to include 30 cities in Santa Cruz Department, an urban area, and the two departments of Beni and Pando in the tropical region in July 2011.
In the target regions in Santa Cruz Department, the planned activities are expected to be completed by the time the Project has ended, and the outputs are also expected to be almost fully achieved. It is also very likely that the Project Purpose will be achieved in this department. However, it is extremely
unlikely that the planned activities will be completed by the time the Project ends in June 2012 in Beni Department and Pando Department as a result of delays to training activities caused by the rainy season. Thus we believe that the expected completion date for the planned activities should be extended to October 2012 in order to confirm the achievement of the various outputs in the two departments and examine their applicability.
This Project is very consistent with Bolivia’s national development plan and Japan’s aid policies. It is also very consistent with Bolivia’s health sector development plan and Intercultural Family and Community Health (Salud Familiar y Comunitaria, or SAFCI), making the Project’s relevance
extremely high. Moreover, its effectiveness is high because the functioning of the five components (hereinafter the “FORSA model”) has been shown to change the awareness and behavior of local residents, not just medical staff. However, there are issues with the Project’s efficiency in that the input of Japanese experts was not sufficient for the Project’s comprehensive management and close monitoring and instability of the staff in Santa Cruz Department and Beni Department led to delays in implementing the Project training. Nevertheless, the ongoing participation of Bolivian counterparts who had been involved in the Project’s predecessor (FORSA1) meant that this accumulated experience could be utilized and the Project was able to benefit from the strong commitment of Bolivian
counterparts such as the Hospital Universitario Japones, committee members, and local staff working on the activities. These factors were very significant in the effective implementation of this Project. Moreover, the spread of activities through this Project and the FORSA model to realize the SAFCI policies nationally can be expected to make future contributions as a specific tool, so the impact will likely emerge over time. There are still issues, such as the need to specify an organization to
coordinate the FORSA model which was strengthened in this Project and secure funding for activities, but we believe that the technological sustainability of the Project is good since the transfer of human resources, including local technicians and medical staff, is limited.
3-5 Recommendations
(1) Recommendations to the Ministry of Health and Sports
1) Expansion to the spread of the FORSA model to realize SAFCI measures
This Project demonstrated that the FORSA model could become a tool to realize SAFCI measures. Thus this model should be expanded to other departments to help improve the health of Bolivia’s citizens.
(2) Recommendations to respective SEDES
1) Completion of Project activities
Plans for the training on medical waste, bio-security, and infectious diseases in hospitals, which was delayed, should be revised and coordinated with JICA so that it can be completed within the Project period.
The training on the FORSA model, intended to contribute to improved health in the region, should be completed within the Project period in the departments of Beni and Pando.
Technicians and medical staff at secondary medical facilities should be given priority in receiving the training on improving repair and maintenance techniques for medical equipment, which should be completed during the Project period.
2) Securing financial resources
Funding for the coordination and management (particularly monitoring and supervision) of activities for the five sub-components in the FORSA model should be secured for the health networks.
After the FORSA model training is complete, funding should rapidly be secured in order to spread and expand the effects of this model, including financial cooperation from other donors.
(3) Recommendations to regional cities
After this Project is over, training activities for the FORSA model will be carried out primarily by the person responsible for each of the sub-components. As a result, cities should continue to budget for these costs (such as transportation costs to the training site) and carry out the training appropriately.
(4) Medium- to long-term recommendations
1) Recommendations to SEDES
The quality of the referral system should be improved, for example by examining the referral criteria in a review of referral patients’ cases and analyzing referral patients’ data. In addition,
counter-referrals should also be made.
In order to support the realization of SAFCI, a Center to Improve the Quality of Medical Technology (provisional name) should be set up as an educational organization for the development of FORSA model capabilities, and the spread and improvement of this model as well as the planning,
administration and coordination of activities should be considered.
3-6 Lessons Learned
(1) Effectiveness of health activities through community participation
This Project confirmed that health activities through community participation using the FORSA model led to changes in the awareness and behavior of residents (the beneficiaries) toward primary medical institutions. In other words, access to health and medical activities notably improved with a stronger spirit of cooperation in the region and implementation of community-based health activities. This helped reduce the number of reported cases of malnutrition and diarrhea in children under five. These health activities carried out with community participation clarified the residents’ needs for local health activities, and a system was developed in which residents played autonomous roles at the activity implementation stage, which in turn led to remarkable results in ensuring the efficiency and sustainability of activities. This output demonstrated the effectiveness of resident involvement in every stage of community health activities, from planning and implementation to feedback.
(2) Developing a highly sustainable operational management system (a system not affected by staff
transfers)
Although Bolivian staff members at the management level were transferred during the Project’s implementation, we confirmed that the impact on the organizations and staff responsible for activities at the local level was minimal. Accordingly, when planning FORSA model activities, the achievement of activity goals and effectiveness can be expected to heighten by developing a highly independent implementation system at the local level.
(3) Utilization of highly universal FORSA model
The FORSA model was developed as a capacity development model that focuses on enhancing medical workers’ technique and improving residents’ health. Subsequently, SAFCI measures were devised by the Ministry of Health and Sports, and the Project indicated that this model can be applied as a means to realize this framework. In other words, a “capacity development model with high technical universality” would be very applicable to measures covering healthcare overall, and can be expected to contribute universally to realizing policy.
(4) System for Project progress supervision (setting and revising activity plans)
This Project began activities with the aim of further expanding the cooperation experiences and output in Japan’s healthcare field, based on JICA’s PCM method, through an operational management system in which Bolivians take the central role. In this case, rather than relying on local staff alone to minutely set and revise the targets to be achieved, output indicators, and activities, Japanese experts who are well-versed in JICA’s PCM method should provide appropriate support.
(5) Development of training supervision system
The FORSA model consists of the five sub-systems that have already demonstrated their effectiveness in strengthening health systems and improving residents’ health. Its effectiveness was demonstrated in this Project as well. However, although training in each of the sub-systems was carried out appropriately, it became clear that training in this model did not incorporate schemes to enhance the replicability of the training content and schemes to plan and administer the training. In order to resolve this issue and make it easier to spread and expand the model to other departments, 1) textbooks for training should be revised and a 2) curriculum and 3) management manual should be prepared to ensure the further usefulness and continuation of the training.
1
第1章 終了時評価調査の概要
1-1 調査団の派遣の経緯と目的 ボリビア多民族国（以下、｢ボリビア｣という）の妊産婦死亡率は290/10万出生（2005 年、WHO 統計情報）、乳幼児死亡率は 63/1000 出生（2003 年ボリビア人口･保健アンケート調査）で、南米 でも最も劣悪な水準である。妊産婦死亡の主な原因は産科合併症であるが、この多くは検診を含む、 適切な周産期ケアが実施できれば防ぐことができるものである。また、乳幼児の死亡原因の大半は急性 呼吸器感染症、下痢症であり、これらの疾病は母親が早い段階で乳幼児を受診させ、適切な処置を 施せば、大半は命を取り留めることができるものである。 しかしボリビアでは、保健医療施設が近隣にないという物理的な問題以外にも、住民の保健医療施 設への不信又は文化的な要因等から、施設の受診に対する抵抗感が根強く存在している。また保健医 療施設においても、医療従事者の能力不足から適切なケアが提供できない場合も少なくない。これらの 複合的な要因により、基礎的な母子保健医療サ－ビスの提供がうまく機能していない状況である。 2001 年 11 月から 2006 年 10 月までの 5 年間実施された｢サンタクルス県地域保健ネットワ－ク強 化プロジェクト（以下、「FORSA SCZ Ph.1」という）｣では、1)保健医療サービスの質の向上（産科・ 小児科）、2)住民参加保健活動、3)レファラル・カウンターレファラルシステムの定着、4) 保健行政・財 政管理システムの構築支援、5)医療機材維持管理体制の構築支援の 5 つの重点分野の活動（以 下、「FORSA モデル」という）を行った。その結果、住民の保健医療サ－ビスへのアクセスがパイロット 地区で向上し、地域住民の健康改善に寄与していることが確認されたため、地域保健システム向上のモ デルとしてサンタクルス県だけでなく、中央政府にも広く認識されるに至った。2 このため、｢地域保健システム向上プロジェクト｣は、FORSA SCZ Ph.1 の成果をボリビア国内へ広く 普及し、地域の保健システムの質を改善させることを目的として、カウンターパート機関を保健スポーツ省、 サンタクルス県保健局とし、2008 年 4 月より 2012 年 6 月までの 4 年間の予定で実施中である。 今般、本プロジェクトが 2012 年 6 月で終了するにあたり、ボリビア政府と合同でプロジェクトの実績、そ して計画に対する達成度を確認するとともに、評価 5 項目（妥当性、有効性、効率性、インパクト、自 立発展性）の観点から評価を行うべく、JICA は終了時調査団を派遣し、評価結果に基づいて、残存 する活動期間の提言を行うとともに、協力終了後に取るべき対応策、また今後の類似事業の実施にあ たっての教訓について協議した。また、合同評価報告書を作成、協議議事録（ミニッツ）を締結した。 1-2 調査団の構成と調査日程 (1) 調査団の構成 担当業務 氏名 所属 期間 団長/総括 松山 博文 JICA ボリビア事務所・所長 2012 年 01 月 29 日-02 月 17 日 協力企画 大里 圭一 JICA ボリビア事務所 第 1 班（保健医療分野）・所 員 2012 年 01 月 29 日-02 月 17 日 技術分析 三好 知明 国立国際医療研究センター・国 際医療協力部・ 派遣協力第 2 課・課長 2012 年 02 月 04 日-02 月 20 日 （現地滞在期間：02 月 05 日 -02 月 18 日） 評価分析 長田 博美 アイシーネット株式会社 2012 年 01 月 28 日-02 月 18 日
